Since 2007, 175 children in Colorado have died of abuse and neglect – beaten, starved, suffocated and burned. Deepening the tragedy is that the families or caregivers of 72 of them were known to caseworkers whose job was to protect them.

Mary Ann Hartman worried the little girl across the street was going to die.

A GRAVE FOR A LITTLE GIRL.

Alize Vick, left, whose body rests at Roselawn Cemetery in Pueblo, was killed at the age of 2 in October 2007 after her foster mother, Jules Cuneo, hurled her five feet, head-first into a coffee table. Based on the reports filed by her foster mother, Alize was extremely accident prone during the five months she lived with Cuneo. But a neighbor, Mary Ann Hartman, could hear what was going on inside the house through a baby monitor and began recording what prosecutors later described as the ongoing torture and abuse of Alize by Cuneo. The recording wouldn’t be enough. (Craig F. Walker, The Denver Post)

Hartman’s baby monitor captured the 23-month-old’s screams and stifled sobs as her 300-pound foster mother sat on her. She recorded the horror coming from the house where the foster mother yelled and ridiculed and the children cried.

Hartman mailed the recording to El Paso County child welfare authorities with a note: “She really needs you. I am doing my part by writing to you, but you must do the rest.”

Then Hartman waited. She called the county when she heard more screaming, when she heard foster mother Jules Cuneo refuse to give the toddler food.

She wondered if anyone would rescue the girl with the toothy grin and big brown eyes.

No one did.

More than 40 percent of the children who died of abuse and neglect in the last six years in Colorado had families or caregivers known to child protection workers who could have saved them.

Those 72 children – many beaten, starved, suffocated or burned – died despite warnings from relatives, neighbors, teachers and strangers, or even the baby monitor recording of blatant abuse sent to caseworkers. Many of their deaths were not only preventable, they were foretold.

It happens, on average, every 30 days. Somewhere in Colorado, a police officer investigates a child’s death from abuse and neglect only to learn the victim is a familiar face to county social workers.

Nine such kids have died so far this year.

A Denver Post and 9News investigation of the Colorado child welfare system revealed a pattern of disturbing failures in which warnings were ignored, cases closed without even a visit and children given to foster parents who killed them.

Caseworkers and their supervisors failed to complete investigations in the time required by law 18 times before children ended up dead. They routinely — at least 31 times — did not contact neighbors and acquaintances who might have told them a child was at risk of harm or even death. More than half of the time, caseworkers violated at least one state rule when conducting abuse investigations, according to an analysis of fatality case reviews by the state Department of Human Services.

The system is plagued by a lack of accountability and transparency — every county in Colorado decides how to run its own child protection department, with minimal input from the state. It is so disjointed, state officials cannot pinpoint the average workload of caseworkers, and cannot fire or discipline a county employee.

Despite years of warnings from expert panels and earnest expressions of concern from three governors and legions of legislators, Colorado’s $375 million system to protect kids from dying remains stubbornly broken.

More kids have died of abuse and neglect in this state in the last five years than in the five years before that, and an increasing number of those children were known to child welfare workers before they were killed. This is despite the highly publicized starving death of 7-year-oldChandler Grafner in 2007 that galvanized attention on the child welfare system.

“It’s 2012, and all the advancements we have in our society, whether it’s technological or medical, we can’t figure out how to keep kids safe?” said Stephanie Villafuerte, director of the Rocky Mountain Children’s Law Center, a nonprofit law firm that often represents foster children. “You are talking about dead children.”

CAREGIVER.

Jules Cuneo, who was the foster mother for 2-year-old Alize Vick, is serving a 32-year prison sentence for the child’s death. (Handout)

No one at El Paso County took Mary Ann Hartman’s letter and baby monitor recording seriously enough.

Alize Vick, the girl across the street, died five months later, in October 2007, after her foster mother hurled her five feet, head-first into a coffee table. Cuneo was enraged because the toddler wouldn’t talk to her.

A caseworker said she listened to the recording and visited the home. But the worker determined it wasn’t enough to take Alize away from Cuneo.

In many other cases that resulted in dead children, a caseworker never came at all.

Almost half of the children known to social services who died of abuse and neglect since 2007 had at least one call “screened out,” or not investigated, because child welfare workers deemed the allegations did not meet the threshold for child abuse or they didn’t have enough information.

Caseworkers had seven chances to help Ciarea Witherspoon‘s family before she was left alone in a bathtub.

Seven times — the majority of them before Ciarea was born — someone called authorities to say things were not right at the family’s house. The allegations piled up.

What would it take for authorities to intervene?

Not the reports of guns and fighting. Not the claims that her father threatened to throw her mother in the trash and that he threatened to kill her. Ciarea’s 7-year-old brother had bruises and went to school with a black eye. Her brother was covered in feces, acted much younger than his age, and he sometimes pretended to slam his head into a wall and said his stepfather hurt him. He told people at school he might get cocaine under the Christmas tree.

In every instance, authorities chose not to intervene. Three of the seven calls were screened out. The four other times, caseworkers assessed whether there were safety threats and ultimately recommended against opening an investigation.

Then in June 2009, 6-month-old Ciarea and her 2-year-old brother were left alone at bath time. By the time her father returned from answering the door and cooking some chicken, she was face down in the water and unresponsive. She lived for nine more months — on a ventilator, with a feeding tube and a leg amputated due to an infection.

As she lay unconscious in the hospital, the state put her in foster care. Ciarea died March 18, 2010.

Problems were “training issues”

Caseworkers assigned to Ciarea’s family violated several state regulations, including failing to interview key people after allegations of abuse prior to the little girl’s death. Arapahoe County officials told The Post there was “absolutely no connection” between the policy violations and the girl’s death, and that the problems were caseworker “training issues.”

That happens regularly.

In more than half of child abuse deaths in the last six years, caseworkers did not follow state policy regarding how to investigate neglect and abuse allegations, according to The Post’s review of state fatality reports. Of 59 reports released to the newspaper, 31 listed violations of state rules.

Caseworkers erred by screening out calls that deserved follow-up, failing to check on children within the time allowed by law and neglecting to communicate with law officers or another county’s child welfare division when a child moved, according to state reviews of the deaths.

Each case is a judgment call, and caseworkers can’t always prevent evil, said Ruby Richards, child protection manager for the Colorado Department of Human Services.

“Caseworkers don’t kill these kids,” she said.

Since 2007, the state has reviewed the deaths of 30 children who had an assigned caseworker — a worker who at minimum was tasked with visiting a home to find out whether ongoing oversight was needed. These are cases where allegations were not screened out but were elevated to require at least one follow-up.

BEHIND CLOSED DOORS.

Maria Gardner stands in her room at the Denver Women’s Correctional Facility in Denver. Gardner poured gasoline over her five children then lit them on fire, killing 16-month-old Ashya Joseph and severely burning the other four on Jan. 28, 2008. In a plea agreement, she pleaded guilty to child abuse causing death and four counts of child abuse causing serious bodily injury. Gardner is now serving 85 years in prison. Gardner says the Department of Human Services should have done more. “They should have taken my children from my home, and they should have put me somewhere ” (Craig F. Walker, The Denver Post)

That included Maria Darlene Gardner and her family.

El Paso County caseworkers were warned on Jan. 23, 2008, by an employee at a family services center that Gardner, distraught over her husband’s suicide, was making funeral arrangements for herself and her five young children.

A caseworker tried to “problem solve” with Gardner and helped her make a plan for babysitting so Gardner could go to therapy. The caseworker called Gardner the next day, and the mother told her she was “fine” and not suicidal. But five days later, on Jan. 28, Gardner gathered her five children in her Colorado Springs home, doused them with gasoline and set them on fire.

“Why did you? … You killed them. Why did you kill them? I loved them,” the 8-year-old boy says during the phone call. The children’s burns covered 20 to 90 percent of their bodies.

Before Gardner set the fire, she looked into a video camera and explained she couldn’t live now that her husband was dead, and she wanted to bring her kids with her. She is serving an 85-year prison sentence.

A state review of Ashya’s death found El Paso County caseworkers had been alerted to problems involving physical abuse in the home six other times, beginning in 2004, but did not remove the children.

The job of a caseworker is partly about following the law and partly about following instinct.

Caseworkers teeter along a thin line of respecting people’s rights to privacy in raising their children and the legal definition of abuse and neglect.

State law says child abuse includes the failure to provide “adequate food,” but that’s not exactly black and white. Just because a child’s home has only a half loaf of bread and Pop-Tarts to last two weeks, that isn’t necessarily cause to assign a caseworker.

The law also says abuse investigators must consider “accepted child-rearing practices” of the child’s culture.

Caseworkers are criticized when they tear children away from their parents and crucified when a child on their watch ends up dead.

“Social services is damned if we do and damned if we don’t,” Richards said.

State officials concede there are failures, times when inaction ends in a child’s death, but that there are examples, too, when a caseworker does everything right and a child still dies.

Gov. John Hickenlooper said caseworkers are “doing some of the hardest jobs on earth” and that state officials are reviewing child deaths, looking for ways caseworkers can improve.

“Was it they were busy? Were they overworked? Did they make several calls and they couldn’t connect on this allegation of neglect? They made three calls and they just got distracted?” he said. “What we’ve tried to do is create solutions for those parts of the problem we control.”

SAYING GOODBYE TO A BABY.

Torrey Brown Sr., 26, talks with his mother Corinthiah Brown and funeral director Jehn-ai Jackson at Caldwell-Kirk Mortuary in Denver on June 3, 2012. Brown was making service arrangements for his son, Torrey Brown Jr., above. The Commerce City Police Department found the remains of the 6-month-old infant May 31, 2012, at the Denver Arapahoe Disposal Site. Sharrieckia Page, 23, the baby’s mother, is charged with first-degree murder and child abuse resulting in death. Torrey Sr. says the Department of Human Services should have done more, “She talked about doing something before. Everybody took her serious but the Department of Human Services. She would call and make threats, ‘I’m going to choke him.'” (Craig F. Walker, The Denver Post)

In the case of little Torrey Brown Jr., a caseworker chose not to intervene after the baby’s grandmother warned his life was in danger.

Torrey’s mother had said he was a crybaby, that she was going to strangle him, that he would end up in a casket, the infant’s father and grandmother recalled.

Torrey’s grandmother, Corinthiah Brown, got to keep Torrey for only one night after she told an Adams County caseworker she feared for his life. Then, after the caseworker told her she was overreacting, Brown said, she was ordered to give him back.

Brown wishes caseworkers had taken her more seriously. And she wishes that even when they didn’t that she hadn’t backed down.

“I tried to stay out of the way,” she said, tears streaking her cheeks as she sat in her Aurora living room. “I never thought it would turn out like this. This is what I get.”

The state does not track whether its child welfare workers are overburdened with work, whether they are overwhelmed with so many kids they don’t try as hard as they should to talk to relatives, neighbors and babysitters to find out whether kids were safe.

Colorado is one of 11 states that do not report caseload data to the federal government.

In this state, each county decides what to pay caseworkers and how much work to give them. Expert panels have suggested the state study staff workloads, but state officials said that is not a priority.

The number of calls reporting alleged child abuse and neglect has jumped 20 percent from 2007 to fiscal 2011, yet the number of investigations opened based on those referrals went up by only 5 percent. In fiscal year 2011, only about half of the 107,854 referrals were investigated.

And state officials do not know whether Colorado has more caseworkers now than it did five or 10 years ago; counties, which are in charge of their workers, aren’t required to tell the state.

Adams County, for one, has three fewer caseworkers now than five years ago. In the same span, annual referrals regarding child abuse and neglect increased by 1,245.

Child advocates question whether there are an adequate number of caseworkers and whether Colorado and its counties spend enough to retain the best workers.

Colorado’s two previous governors — a Democrat and a Republican — zeroed in on one key flaw that hinders child safety in Colorado: a county-run child welfare system with limited state oversight.

After 7-year-old Grafner’s death in 2007, then-Gov. Bill Ritter, a Democrat, created an expert panel to study child welfare. Grafner, who starved to death, had been trapped in a linen closet with no food or water and only a litter box to go to the bathroom, even as school officials called child welfare authorities.

The panel of child welfare experts wanted a statewide hot line to report child abuse, a central place to screen calls. And they wanted a regionalized system, where rural counties would combine resources and expertise.

“We looked at the urgency of this because of the well-being of children, who one way or another seemed to be falling through the cracks in the most fatal ways,” said Ritter, who called the “turf issue” with counties one of the most contentious of his tenure. It was “terribly frustrating,” he said, that his child welfare task force could not get statewide data because each county has its own authority.

“We have a real challenge because authority is so diffused,” he said. “Where you would think that a governor and a state have the responsibility and authority, in many cases they don’t. While many of our counties have very strong departments of social services, regrettably, some do not, and it’s very hard to establish statewide accountability and structure when there are such huge variations.”

Hickenlooper stopped short of calling for less county control, but said he might consider it in a few years if his administration’s reforms don’t work.

Hickenlooper’s key effort is a state scoring system, created by the new director of the Colorado Department of Human Services, that rates counties’ handling of child abuse investigations. He hopes public pressure will encourage county departments to improve their work, even though county-by-county ratings do not appear on a state website that shows how the state stacks up against federal guidelines and past performance.

“We are always going to be one step removed because the counties are going to have that ultimate control,” Hickenlooper said. “Now the only way that I can see that the state can begin to exert serious authority … is through transparency.”

It’s one reform in a list of overhauls announced by Human Services director Reggie Bicha, who took over the department in January. He also has called for clearer and more consistent procedures across all counties.

“We are trying to shift a huge ocean liner in our child welfare culture in Colorado,” Bicha said. “I want us to turn the boat in a better direction for kids and families.”

About 30 kids, on average, die of abuse and neglect in Colorado each year, putting the state among the top half nationally in per-capita death rates. Since 2007, 175 children have died of abuse and neglect in Colorado.

“It’s all of our fault,” said Skip Barber, executive director of the Colorado Association of Family and Children’s Agencies, a group of not-for-profit advocacy agencies.

More often than not, child abusers are the children’s own parents, a relative or their mother’s boyfriend. Those are the people to blame.

But the blame stretches further, experts said.

“Children don’t vote. They don’t have a strong enough advocacy,” said Tracey Feild, director of the child welfare strategy group at the Annie E. Casey Foundation. “There is an assumption that abused and neglected children are only ‘those’ people.”

Clearly, though, even when people plead for help, that is not always enough.

The El Paso County caseworker who listened to the baby monitor audio recordings of 2-year-old Alize Vick said there wasn’t enough evidence to remove Alize from the foster home. The worker was reassigned to another county job, and the county revamped its practices so it could, among other things, react faster to help children in danger. The foster mother, Cuneo, is serving a 32-year prison sentence.

The girl’s neighbor who had recorded the abuse, Mary Ann Hartman, would tell a state Senate committee that El Paso County ignored her.

“I believe that preconceived ideas and attitudes can run through an institution like a virus,” she said. “I was met with skepticism and disrespect.”

“I was in total disbelief … I was trying to save a little girl, and they would not believe me,” she said. “I kept telling them, she is going to kill the little girl. She will kill her, and they still did not believe me.”

Child fatality reviews

When a child who was part of the child welfare system dies of abuse or neglect in Colorado, county and state officials complete a child fatality review. Many of the findings in this series come from those reports.

Caseworkers, county child protection supervisors and state officials review each fatal case — including any referrals involving the family before the child was born — to create a detailed history of involvement in the system. The review team identifies any risk factors that were present for the child or the family before the death.

The review determines whether there were any concerns or policy violations in the way caseworkers investigated claims of child abuse or neglect, said Ruby Richards, child protection manager for the state.

But the parameters for when and how a report is completed have fluctuated.

In 2011, state officials excluded an unknown number of children’s deaths from ever being reviewed by decreasing the amount of time within the child welfare system — from within the last five years to within the last two years — necessary to trigger a review.

Also, beginning in 2012, reports provided fewer details about the child and the child’s family history with the department, Richards said. Instead of a narrative style, information was provided in a list format. The reports also listed fewer violations of state regulations, noting the violations only if officials determined they were “systemic” concerns.

“Pointing out an isolated issue doesn’t seem fair,” Richards said earlier this year.

In the course of a Denver Post investigation, state officials stopped the release of any other reports so that they could redo them in a format they say is more transparent.

Jennifer Brown is an investigative reporter for The Denver Post, where she has worked since 2005. She has written about the child welfare system, mental health, education and politics. She previously worked for The Associated Press, The Tyler Morning Telegraph in Texas, and the Hungry Horse News in Montana.

Christopher N. Osher is a reporter on the investigation team at The Denver Post who has covered law enforcement, judicial and regulatory issues for the news organization. He also has reported from war zones in Africa.

Jordan Steffen was the legal affairs reporter for The Denver Post. She left the organization in June 2016 after joining in January 2011. Her past coverage areas included breaking news, child welfare, the western suburbs and crime. She was raised in the Colorado mountains and graduated from the University of Colorado Boulder.

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